Medicare Compliance & Reimbursement

Make sure your documentation is in order before billing separate E/M service.

If you weren’t already worried about audits of the 25 modifier, it’s definitely time to start paying attention.

Your documentation for the 25 modifier will be under heavy scrutiny soon, judging from Transmittal 954, issued May 19 by the Centers for Medicare & Medicaid Services (CMS). In this transmittal, CMS:

· adds the word “usual,” so the guidelines now read: “a significant, separately identifiable E/M service that is above and beyond the usual pre- and post-operative work for the service.” The addition is just meant to emphasize that any extra E/M service must be “above and beyond” the typical pre-op or post-op work, says Quinten Buechner with ProActive Consultants in Cumberland, WI.

· clarifies that you don’t need a different diagnosis for the E/M service and surgery.

· stresses you must make sure that you have appropriate documentation proving the medical necessity of the separate same-day E/M service. You don’t need to submit this documentation with the claim, but it must be available upon request.

None of these changes is major, says Lisa Center, coder with Mount Carmel Regional Medical Center in Pittsburg, KS. But it’s safe to say the 25 modifier “will be under more scrutiny.”

Bottom line: If your doctor already plans a procedure and does a pre-op workup, then don’t bill for a separate E/M. But if the physician doesn’t know if an operation will be necessary and must rule out other options, then you can bill for the E/M where the doctor reaches the decision for surgery, says Center.

Example: Say a new patient comes in with multiple skin lesions, and the physician does an excisional biopsy of one of them. The physician takes a history and a review of systems, takes a family history of malignancy, and examines the patient’s lymph system, as well as neurological and cardiovascular systems. Then the physician decides which lesions to remove and removes them, says Dianne Wilkinson, compliance officer and quality manager with MedSouth Healthcare in Dyersburg, TN.

If the physician documents everything that happened, you can easily bill for a separate E/M service. But if the physician only documents that he or she examined and removed some lesions, and did an excisional biopsy, then you can only bill for the procedures, Wilkinson says.